Effect of Core Stability Exercises and Treadmill Training On Balance in Children With Down Syndrome - Randomized Controlled Trial [PDF]

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Adv Ther https://doi.org/10.1007/s12325-019-01024-2



ORIGINAL RESEARCH



Effect of Core Stability Exercises and Treadmill Training on Balance in Children with Down Syndrome: Randomized Controlled Trial Reham Saeed Alsakhawi



. Mohamed Ali Elshafey



Received: April 26, 2019 Ó Springer Healthcare Ltd., part of Springer Nature 2019



ABSTRACT Introduction: Core stability exercises and treadmill training play a crucial role in physical therapy interventions and have an effect on balance in children with Down Syndrome (DS); however, whether core stability exercises or treadmill training has more effect on improving balance has not been investigated yet. The aim of the study was to investigate the effect of core stability training versus treadmill exercises on balance in children with Down Syndrome. Methods: Forty-five children aged 4–6 years with Down Syndrome were included in the study. The children were equally divided randomly into three groups. Group A received traditional physical therapy intervention strategies to facilitate the balance of participating children. Group B received the same as group A and additional core stability exercise training. Enhanced digital features To view enhanced digital features for this article go to https://doi.org/10.6084/ m9.figshare.8325431. R. S. Alsakhawi
M. A. Elshafey The Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt R. S. Alsakhawi (&) Rehabilitation Sciences Department, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia e-mail: [email protected]



Group C received the same intervention strategies as group A in conjunction with a treadmill exercise program. The children’s balance was evaluated using the Berg balance scale and the Biodex Balance System. Treatment sessions were for 60 min, thrice a week, for 8 consecutive weeks. Results: There were significance improvements in the three groups in functional balance and over all stability indices in favor of groups B and C. Conclusions: Core stability and treadmill training improved balance in children with Down Syndrome and should be applied in conjunction with physical therapy programs. Keywords: Balance; Berg balance scale; Biodex balance system; Core stability; Down Syndrome; Treadmill



INTRODUCTION Down Syndrome (DS) is the most common type of genetic disorder [1, 2]. Children with DS have a small sized brainstem and delayed cerebellar maturation. Lack of training programs and limited motor experience result in motor disturbances and decreased balance capacity of these children when compared to their typically developing peers [2, 3]. Children with DS have a significant delay in the development of motor skills with qualitative differences in movement



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patterns compared to children without DS [4–6]. Children with DS have difficulty maintaining body posture, and coupled with an abnormal gait pattern, there are an increased number of falls [2, 7]. Little research supports the use of core stability to improve balance and postural stability in children with DS. Ghaeeni et al. [2] reported that the improvement of the static balance of children with DS is one of the benefits of core stability exercises. It does so by increasing the power and endurance of all the muscles of the core stabilization area (deep and superficial). Aly and Abonour [7] mention that the therapist can use the core stability training as physical therapy modality for children with DS that have balance problems, and can therefore be used to reduce the risk of falling and related injuries. The terms ‘‘core’’ and ‘‘core exercise’’ have been the most commonly used in recent years [8–10]. Studies in the field of enhancing the balance functions in children with disabilities were interested in core stability exercises [2, 11]. The term ‘‘core’’ or ‘‘core stability’’ includes anterior aspect muscles like the abdominals, the gluteal and paraspinal muscles posteriorly, and the pelvic floor with hip girdle musculature inferiorly [2, 12, 13]. The aim of core stability training is to achieve the optimal physical ability to maintain the normal state of the spine in daily activities, in addition to developing the endurance and coordination of these core stability muscles [2, 14–16]. Different studies investigated the impact of treadmill training on dynamic balance in children with DS. Treadmill training of infants with DS is a scheduled and typically prescribed physical therapy intervention aiming to reduce the delay in the onset of walking [6]. Treadmill exercises stimulate the kinetic, kinematic, and temporal features of walking. These exercises improve the strength of the muscles of the lower extremities, enhance motor learning, improve functional abilities, and activate the locomotor control system [17–19]. Using the treadmill program regularly has similar benefits for elderly adults with DS and improves the strength of lower limbs, balance, and walking skills. This improvement leads to improvement



in daily activities and the functional capabilities of individuals with DS [20]. Previous research has demonstrated improvement in balance in children with Down Syndrome by using core stability training [7]. Other research indicates that balance and lower extremity strength in children with DS can be improved by using treadmill exercise. This led to an improved gait pattern sooner than in children with no treadmill exercise programs [6, 20–24]. The purpose of this study is to compare the effectiveness of core stability training versus treadmill training on dynamic balance in children with DS.



METHODS Study Design The current research is a randomized controlled trial to differentiate between the effect of core stability exercises versus treadmill training on dynamic balance in children with DS. Subjects Forty-five children with DS of both sexes participated in this research, and their age ranged from 4 to 6 years (mean 4.59 ± 0.53). The children were recruited from an outpatient clinic, the Faculty of Physical Therapy, Cairo University, Egypt. The children in this study were selected according to the following criteria: able to recognize commands given to them, understand our verbal command and encouragement, and stand and walk independently without repeated falling. Children with any neurological (signs of epilepsy and instability of atlantoaxial joint), musculoskeletal, or mobility disorders, cardiac anomalies, vision or hearing loss were excluded. This study was approved by the Ethical Committee of the Faculty of Physical Therapy, Cairo University, Egypt (No: P.T.REC/013/ 001928) and it is in accordance with the Declaration of Helsinki of 1964 and its later amendments. A consent form given to parents of potential participants described the



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procedures and purpose of the study in detail. Researchers administered a brief structured interview to screen children according to the research criteria and gather their demographic information. After rapport-building, instruments were administered to children, and parents of participants were assured of the confidentiality of the information about their children.



and C). This study was conducted from January to April to 2019. The 15 children with DS in group A (control group) received a traditional exercise program with instructions given to the children [7, 24, 31] for 60 min aiming to improve posture control and balance (Table 1). The 15 children with DS in group B received the same program as group A (for 30 min) in



Measures



Table 1 A traditional exercise program used in group A to improve postural control and balance



Berg Balance Scale The Berg balance scale is a clinical assessment of functional balance. It consists of 14 functional tasks of increasing difficulty, and each is scored on a scale ranging from 0 to 4 (task is performed independently = 4; unable to complete the task = 0). The maximum possible score is 56 which indicates no identifiable balance difficulties [25, 26]. The inter-rater reliability of Berg balance scale is 0.97 (95% CI 0.96–0.98) and the intra-rater reliability is 0.98 (95% CI 0.97–0.99) [27]. Biodex Balance System (Biodex Medical Systems, Version 3.1) The Biodex Balance System (BBS) is used to adjust the stability of a suspended circular force plate. The force platform has a maximum of 20° tilt in any direction when completely unstabilized and determines the stability of the participant based on the variance of the platform from the center [28]. The BBS is an objective and reliable assessment for measuring the dynamic balance (the reliability indices of medial–lateral stability, anterior–posterior stability, and overall stability are 0.43, 0.80, and 0.82, respectively) [29, 30]. It was designed to assess neuromuscular control and stimulate joint mechanoreceptors through the ability to maintain dynamic postural stability [30]. Procedure Names of children that met the inclusion criteria of the study were collected and uploaded to an electronic program (SPSS) that divided the sample randomly into three equal groups (A, B,



Exercise



Description



The child stood with feet closed together



The therapist sat behind the child and locked the child’s knees manually, then slowly tilted the child forward, backward, and sideways



The child stood with one foot step forward (stepstanding)



The therapist stood behind the and child guided the child to shift their weight alternating in forward and backward directions



The child stood with one foot on a block (high step-standing)



The child tried to keep the balance of the body



Standing child



The therapist locked the child’s knees manually and the child tried to stoop and recovery actively Child applied postural reactions training (righting, tilting equilibrium, and protective reactions)



Walking exercises (one of Walking across obstacles the most important parts (blocks, books, wedges, of dynamic balance) and rolls of different sizes) in three directions: backwards, forwards, and sideways



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addition to treadmill training. The child walked on the treadmill (motorized treadmill, ENTRED, Enraf–Nonius) at 75% of over-ground speed and individually prescribed low-endurance walking at 0% incline [20] for 20 min, three times a week for 8 successive weeks [24, 32]. The walking area of the treadmill is made from heavy steel with a minimum 8-inch thickness and is available with cushioning in case of accidental impacts. Before the walking session, each child underwent 5 min of active stretching exercises that include prolonged and progressive stretching of the hamstrings, quadriceps muscles, and Achilles tendon [20]. Children were in an upright position when standing on the treadmill, and the therapist adjusted the elevation of the handrails according to each child. As much as possible, the child was kept looking forwards to stimulate the setting of independent walking. The child completed treadmill training under three conditions in 1-min training cycles. For 15 s of each minute the child could hold on to the railings with both hands, for the next 15 s with one hand, and finally with no hands on the handrails for 30 s. Each child repeated this procedure 20 times [24, 33]. At the end of the procedure, there was a 5-min cooldown. Each child wore street clothes and sports shoes during the procedure. There was conversation between the therapist and the child during where their interests were discussed, and motivation was continually provided. The 15 children with DS in group C received the same traditional physical therapy exercises as group A (for 30 min) in addition to core stability training. Jeffrey’s core stability exercises (Table 2) were performed for 8 weeks, with three 30-min sessions per week [2, 7, 34, 35]. Jeffrey’s protocol included lumbar-pelvic proprioception retraining, specific spinal stabilization exercises, different muscle contractions, and abdominal maneuvers. After completion of those exercises, using dynamic stability was exercised, and the children needed to maintain stabilization in various positions such as squatting, supine, and prone. The dynamic components made use of Swiss ball and limb (upper or lower limb) movement in advanced stages. The previous exercises [7, 34, 36] included three phases:



Phase 1 consisted of a fixed position with isometric contractions, and a slow movement in an unstable setting for difficulty progression. Phase 2 began in an unbalanced position to a more balanced one with isometric contractions with the aim to increase the endurance of the movements in an unbalanced position. Phase 3 was done by using the child’s weight, and dynamic movements with Swiss and Madison balls were done. Statistical analysis The statistical analyses were calculated using Statistical Package for the Social Sciences (SPSS) version 20. All data in the current study were presented as means and standard deviations. The differences between the pre- and posttreatment measurements were evaluated using a paired t test. The differences between the three groups were analyzed using one-way analysis of variance (ANOVA) followed by least-square difference (LSD) post hoc test. The level of significance for all tests in this study was set at 0.05.



RESULTS Demographic Characteristics There were no statistically significant differences between three groups (A, B, and –C) in age (p = 0.69), weight (p = 0.52), height (p = 0.97), and gender (p = 0.59). Comparing Between the Three Groups Before Treatment There were no statistically significant differences in functional balance and overall stability index pre-treatment between the three groups (p [ 0.05) (Table 3). Comparing Between Pre and Post Treatment Among Three Groups There was a statistically significant improvement in functional balance and overall stability



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Table 2 Jeffrey’s core stability exercises [37, 38] Week



Form of exercise



The volume and intensity of exercise



1 and 2



Contracting abdominal muscles while lying in a supine position



Three sets and 20 repetitions in each set



Contracting abdominal muscles while lying in a prone position



Three sets and 20 repetitions in each set



Contracting abdominal muscles while in a squat position



Three sets and 20 repetitions in each set



3



Contracting abdominal muscles while lying in a supine position with one Three sets and 20 repetitions in each leg stretched and the other bent at the knee and pressed against the set abdomen Contracting abdominal muscles while lying in a prone position with one Three sets and 20 repetitions in each set leg stretched and the body weight on the other leg which is bent at the knee



4



5



6



Side lying bridge for each side of the body



Six repetitions, a 10-s pause



Contracting abdominal muscles while lying in a supine position and pulling the limbs upward with arms and legs kept close



Three sets and 20 repetitions in each set



In squat position, one leg is raised and pulled outward and backward



Three sets for each leg and 20 repetitions in each set



Trunk rotation while holding weights in each hand



Three sets each part of the body and 20 repetitions in each set



Sitting on a Swiss ball and holding the abdomen in



Three sets, 10 s



Squatting while the Swiss ball is on the shoulder



Three sets and 15 repetitions for each set



Bringing up the arms and legs simultaneously in the prone position



Three sets and 15 repetitions for each set



Bending 45° to the left or right



Three sets for each side, 12 repetitions in each set



Bridging while shoulders and hands are on the floor and one leg is raised Three sets for each leg, 15 repetitions in each set



7



Contracting abdominal muscles while lying in a supine position on the Swiss ball



Three sets, 12 repetitions in each set



Lying supine on the Swiss ball and rotating the trunk to the sides



Three sets and 15 repetitions for each set



Doing the above exercise with holding weights in the hands



Three sets and 15 repetitions for each set



Side lying bridge with bringing up the leg



Six repetitions for each side of the body and a 10-s pause



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Table 2 continued Week



Form of exercise



The volume and intensity of exercise



8



Lying supine on the Swiss ball and holding the abdomen in and bringing Three sets, 12 repetitions in each set one leg up Raising the opposite arm and leg while squatting



Three sets, 12 repetitions in each set



Bridge so that the feet are placed on the Swiss ball and raise one leg



Three sets and a 15-s pause for each set



Table 3 Pretreatment statistics for the three groups Variable



 – SD) Group A (X



 – SD) Group B (X



 – SD) Group C (X



p value



Functional balance



32.5 ± 3.8



31.7 ± 3.3



33.2 ± 2.5



0.61



Overall Stability Index



4.20 ± 0.406



4.6 ± 0.289



5.1 ± 0.15



0.42



 ± SD mean ± standard deviation, p level of significance X



Table 4 Pre- and post-treatment statistics for three groups Variable Group



Functional balance Pre



Post



 ± SD) Group A (X



32.5 ± 3.8



38 ± 2.58



 ± SD) Group B (X



31.7 ± 3.3



 ± SD) Group C (X



33.2 ± 2.5



p value



0.61



p value



Overall stability index



p value



Pre



Post



0.001*



4.20 ± 0.40



5.40 ± 0.70



0.001*



43.8 ± 2.91



0.001*



4.6 ± 0.289



6.9 ± 0.33



0.001*



45 ± 2.12



0.001*



5.1 ± 0.15



7.4 ± 0.54



0.001*



0.42



0.27



0.15



 ± SD mean ± standard deviation, p level of significance X



*Significant



index for the three groups after treatment (p \ 0.05) (Table 4). Comparing Between Three Groups After Treatment Post hoc test statistics demonstrated that there was statistically significant improvement in group B and group C in functional balance and overall stability index compared to group A (p \ 0.05), but there was no statistically significant difference between group B and group C in functional balance and overall stability index (p [ 0.05).



DISCUSSION The purpose of this study was to determine if core stability exercises were more effective than treadmill training exercises on balance in children with DS or vice versa. The outcomes in the current study demonstrated that there was not a significant difference of balance improvement between treadmill exercises and core stability exercises after treatment in children in groups B and C, while there was improvement in the three groups in functional balance and overall stability indices in favor of groups B and C. Previous research studied the effect of treadmill



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training exercises on balance and others studied the improvement of balance by using core stability exercises in children with DS. All the research results showed a statistically significant improvement in the balance. There are not enough available studies reporting a comparison between the effect of treadmill training and core stability exercise on balance in children with DS. Previous research approves and supports the outcomes of this study and that there are no statistically significant differences between the effectiveness of the core stability exercises and treadmill training exercises on balance in children with DS. Both training exercises improved muscle strength in different ways resulting in improvement of balance. Ghaeeni et al. [2] investigated the improvement of static balance by using the core stability exercise training in children with DS. The outcomes of their study indicated that the experimental group had significant improvement of static balance compared to the control group. Their results showed that progressive resistance training improves balance capacity in children with DS. The progressive resistance training elements that were present in the training program of their study were in the form of weight-bearing exercises. This led to improved balance by increasing muscle strength [39]. Moreover, Carmeli et al. [19] investigated the efficacy of treadmill training on the muscle strength and balance in elderly people with DS. They found significant improvements in the strength of lower extremity muscles, dynamic balance, and walking function. Their study indicated that measurements of mean peak torque, the power of hamstrings and quadriceps muscles, in addition to the parameters of the dynamic balance of elderly people with DS were improved after 6 successive months of treadmill exercises. They suggested that the improved balance was due to improved knee muscle performance. These results are supported by several studies also reporting the positive effects of walking training programs on endurance, muscle strength, and balance in elderly people [2, 40]. While there was no significant difference when comparing between groups B and C after treatment, both treadmill exercises and core



stability exercises have been demonstrated to be effective compared with group A (control group). Utilization of various treadmill interventions improved the development of joint kinematics in infants with DS. Previous study found the treadmill interventions to be beneficial on neuromuscular coordination development [23]. In terms of core stability, Aly and Abonour [7], Norris [40], and Gribble and Hertel [41] found improvements in acceleration and deceleration, optimal lumbar–pelvic–hip chain mobility, appropriate proximal stability, proper function, and muscular balance. Improved lower extremity muscle strength was more able to control the movement. On the other hand, the non-significant difference in balance between groups B and C after treatment in this study could mean that both training programs have a similar effect on gait patterns through an improvement of static and dynamic balance. Changes in walking velocity and gait parameters by using trunk coordination have been investigated [12, 42]. In cadence, the core stabilization exercise group showed more improvement than the control group, but there was no statistically significant difference between these groups. The core stability training exercises might improve the postural stability of the pelvis, and lower trunk. This results in an increased ability in static and dynamic balance when the weight is supported by the lower limbs and may ultimately contribute to more stability during gait. Moreover, Ulrich et al. [5] suggested that treadmill training of infants with DS is a critical supplement to regular physical therapy treatment strategies to decrease the delay in beginning to walk. Increasing the intensity of treadmill training increases the step rate. It is recommended that research should study the long-term effects of the treadmill training on the ability of the child to cross obstacles in its pathway and maintain balance during the movement. This is because children with DS are more likely to lose their balance when coming across obstacles in their surroundings [20, 24, 42]. The small sample size is a limitation in this study and may impact the generalization of the results. The other limitation is that the effect of



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interventions was measured immediately after the period of treatment which was 3 months, so it is not certain if the effect is sustained for the long term.



CONCLUSION Core stability exercises and treadmill training exercises improved balance in children with DS. Our study suggests that the physical therapist can use either of the physical therapy modalities in this research (core stability exercise or treadmill exercise) in conjunction with traditional physical therapy programs to improve the balance in children DS. It was found that both physical therapy modalities significantly improved balance.



Data Availability. The datasets generated during and/or analyzed during the current study are not publicly available (this paper is our work and it is part of our project that is not finished yet) but are available from the corresponding author on reasonable request.



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Disclosures. Reham Saeed Alsakhawi and Mohamed Ali Elshafey have nothing to disclose.



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ACKNOWLEDGEMENTS The authors would like to thank all participating children and their parents; in addition, the staff of the outpatient clinic of the Faculty of Physical Therapy, Cairo University. Egypt. Funding. No funding or sponsorship was received for this study or publication of this article. The article processing charges were funded by the authors.



Compliance with Ethics Guidelines. This study was approved by the Ethical Committee of the Faculty of Physical Therapy, Cairo University, Egypt (No: P.T.REC/013/001928) and it is in accordance with the Declaration of Helsinki of 1964 and its later amendments. The parents of all participating children signed consent forms for participation.



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